Healthcare Provider Details

I. General information

NPI: 1538422688
Provider Name (Legal Business Name): MELBA DOLORES LOPEZ DE VICTORIA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 07/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1304 OAK ST
MELBOURNE FL
32904-3111
US

IV. Provider business mailing address

1707 SIENNA DR
MELBOURNE FL
32934-9030
US

V. Phone/Fax

Practice location:
  • Phone: 321-723-4723
  • Fax: 321-727-1448
Mailing address:
  • Phone: 321-286-6085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9223165
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: